1
|
Comerlato PH, Stefani J, Viana LV. Mortality and overall and specific infection complication rates in patients who receive parenteral nutrition: systematic review and meta-analysis with trial sequential analysis. Am J Clin Nutr 2021; 114:1535-1545. [PMID: 34258612 DOI: 10.1093/ajcn/nqab218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/08/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Parenteral nutrition (PN) is an available option for nutritional therapy and is often required in the hospital setting to overcome malnutrition. OBJECTIVES The aim of this study was to assess whether PN is associated with an increased risk of mortality or infectious complications in all groups of hospitalized patients compared with those receiving other nutritional support strategies. METHODS For this systematic review and meta-analysis MEDLINE, Embase, Cochrane Central, Scopus, clinicaltrials.gov, and Web of Science were searched for randomized controlled trials (RCTs) and observational studies with parallel groups that explored the effect of PN on mortality and infectious complications, published until March 2021. Two independent reviewers extracted the data and assessed the risk of bias. Fixed-effects meta-analysis was performed to compare the groups from RCTs. Trial sequential analysis (TSA) was used to identify whether the results were sufficient to reach definitive conclusions. RESULTS Of the 83 included studies that compared patients receiving PN with those receiving other strategies, 67 RCTs were included in the meta-analysis. PN was not associated with a higher risk of mortality (RR: 1.01; 95% CI: 0.95, 1.07). On the other hand, PN was associated with a higher risk of infectious events (RR: 1.23; 95% CI: 1.12, 1.36). PN was specifically associated with abdominal infection and catheter infection. The TSA showed that there were sufficient data to make numerical conclusions about mortality, any infectious event, and abdominal infectious complications. CONCLUSIONS This study suggests that although PN is not associated with greater mortality in hospitalized patients, it is associated with infectious complications. Through TSA, definite conclusions about survival and infection rates could be made.This review was registered at www.crd.york.ac.uk/prospero/ as CRD42018075599.
Collapse
Affiliation(s)
- Pedro H Comerlato
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Joel Stefani
- Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Luciana V Viana
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| |
Collapse
|
2
|
Salciute-Simene E, Stasiunaitis R, Ambrasas E, Tutkus J, Milkevicius I, Sostakaite G, Klimasauskas A, Kekstas G. Impact of enteral nutrition interruptions on underfeeding in intensive care unit. Clin Nutr 2020; 40:1310-1317. [PMID: 32896448 DOI: 10.1016/j.clnu.2020.08.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/06/2020] [Accepted: 08/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care. METHODS This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available. RESULTS In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001). CONCLUSIONS The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.
Collapse
Affiliation(s)
- Erika Salciute-Simene
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
| | - Raimundas Stasiunaitis
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eduardas Ambrasas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jonas Tutkus
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Gintare Sostakaite
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Andrius Klimasauskas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Gintautas Kekstas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| |
Collapse
|
3
|
Roberts KM, Nahikian-Nelms M, Ukleja A, Lara LF. Nutritional Aspects of Acute Pancreatitis. Gastroenterol Clin North Am 2018; 47:77-94. [PMID: 29413020 DOI: 10.1016/j.gtc.2017.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The goal of nutritional support in acute pancreatitis is to reduce inflammation, prevent nutritional depletion, correct a negative nitrogen balance, and improve outcomes. Enteral nutrition (EN) in severe acute pancreatitis (SAP) should be preferred to parenteral nutrition. It maintains the integrity of the gut barrier, decreases intestinal permeability, downregulates the systemic inflammatory response, maintains intestinal microbiota equilibrium, and reduces the complications of the early phase of SAP, improving morbidity and possibly improving mortality, and it is less expensive. Further studies to understand optimal timing of nutrition, route of delivery of EN, and the type of nutrition and nutrients are necessary.
Collapse
Affiliation(s)
- Kristen M Roberts
- Division of Gastroenterology, Hepatology and Nutrition, School of Health and Rehabilitation Sciences, The Ohio State University, 453 West 10th Avenue, Columbus, OH 43210, USA
| | - Marcia Nahikian-Nelms
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, 453 West 10th Avenue, Columbus, OH 43210, USA
| | - Andrew Ukleja
- Department of Gastroenterology, Digestive Disease Institute, 2950 Cleveland Clinic Florida, Weston FL 33331, USA
| | - Luis F Lara
- Division of Gastroenterology, Hepatology and Nutrition, Wexner Medical Center, The Ohio State University, 395 West 12th Avenue, 2nd Floor Office Tower, Columbus, OH 43210, USA.
| |
Collapse
|
4
|
Ridley EJ, Davies AR, Parke R, Bailey M, McArthur C, Gillanders L, Cooper DJ, McGuinness S. Supplemental parenteral nutrition versus usual care in critically ill adults: a pilot randomized controlled study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:12. [PMID: 29361959 PMCID: PMC5781264 DOI: 10.1186/s13054-018-1939-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/02/2018] [Indexed: 12/29/2022]
Abstract
Background In the critically ill, energy delivery from enteral nutrition (EN) is often less than the estimated energy requirement. Parenteral nutrition (PN) as a supplement to EN may increase energy delivery. We aimed to determine if an individually titrated supplemental PN strategy commenced 48–72 hours following ICU admission and continued for up to 7 days would increase energy delivery to critically ill adults compared to usual care EN delivery. Methods This study was a prospective, parallel group, phase II pilot trial conducted in six intensive care units in Australia and New Zealand. Mechanically ventilated adults with at least one organ failure and EN delivery below 80% of estimated energy requirement in the previous 24 hours received either a supplemental PN strategy (intervention group) or usual care EN delivery. EN in the usual care group could be supplemented with PN if EN remained insufficient after usual methods to optimise delivery were attempted. Results There were 100 patients included in the study and 99 analysed. Overall, 71% of the study population were male, with a mean (SD) age of 59 (17) years, Acute Physiology and Chronic Health Evaluation II score of 18.2 (6.7) and body mass index of 29.6 (5.8) kg/m2. Significantly greater energy (mean (SD) 1712 (511) calories vs. 1130 (601) calories, p < 0.0001) and proportion of estimated energy requirement (mean (SD) 83 (25) % vs. 53 (29) %, p < 0.0001) from EN and/or PN was delivered to the intervention group compared to usual care. Delivery of protein and proportion of estimated protein requirements were also greater in the intervention group (mean (SD) 86 (25) g, 86 (23) %) compared to usual care (mean (SD) 53 (29) g, 51 (25) %, p < 0.0001). Antibiotic use, ICU and hospital length of stay, mortality and functional outcomes were similar between the two groups. Conclusions This individually titrated supplemental PN strategy applied over 7 days significantly increased energy delivery when compared to usual care delivery. Clinical and functional outcomes were similar between the two patient groups. Trial registration Clinical Trial registry details: NCT01847534 (First registered 22 April 2013, last updated 31 July 2016) Electronic supplementary material The online version of this article (10.1186/s13054-018-1939-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia. .,Nutrition Department, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Rachael Parke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Colin McArthur
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Lyn Gillanders
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Nutrition and Dietetics, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, VIC, 3004, Australia
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | | |
Collapse
|
5
|
Hegazi RA, DeWitt T. Enteral nutrition and immune modulation of acute pancreatitis. World J Gastroenterol 2014; 20:16101-16105. [PMID: 25473161 PMCID: PMC4239495 DOI: 10.3748/wjg.v20.i43.16101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 05/09/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Enteral nutrition has been strongly recommended by major scientific societies for the nutritional management of patients with acute pancreatitis. Providing severe acute pancreatitis patients with enteral nutrition within the first 24-48 h of hospital admission can help improve outcomes compared to parenteral nutrition and no feeding. New research is focusing in on when and what to feed to best improve outcomes for acute pancreatitis patients. Early enteral nutrition have the potential to modulate the immune responses. Despite this consistent evidence of early enteral nutrition in patients with acute pancreatitis, clinical practice continues to vary due to individual clinician preference. Achieving the immune modulating effects of enteral nutrition heavily depend on proper placement of the feeding tube and managing any tube feeding associated complications. The current article reviews the immune modulating effects of enteral nutrition and pro- and prebiotics and suggests some practical tools that help improve the patient adherence and tolerance to the tube feeding. Proper selection of the type of the tube, close monitoring of the tube for its placement, patency and securing its proper placement and routine checking the gastric residual volume could all help improve the outcome. Using peptide-based and high medium chain triglycerides feeding formulas help improving feeding tolerance.
Collapse
|
6
|
Abstract
Severe acute pancreatitis (SAP) patients often have high catabolism, negative nitrogen balance and high energy consumption, and the degree of negative nitrogen balance is directly related to the severity of the disease. The purpose of nutritional support is to establish positive nitrogen balance. In nearly a decade, evidence-based evidence suggests that enteral nutrition can reduce the incidence of pancreatic infection, organ failure and mortality. Enteral nutrition is not only a way of nutritional support, but also for the treatment of SAP. However, there are some debates over the timing, ways, nutrient solution composition and the use of ecological immune preparations. In this review, we focus on the proper timing, way and nutrient solution composition of EN.
Collapse
|
7
|
Passier RHA, Davies AR, Ridley E, McClure J, Murphy D, Scheinkestel CD. Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement. Intensive Care Med 2013; 39:1221-6. [PMID: 23636828 DOI: 10.1007/s00134-013-2934-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 04/11/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Delivery of enteral nutrition (EN) to ICU patients is commonly interrupted for diagnostic and therapeutic procedures. We investigated this practice in a cohort of trauma and surgical ICU patients. METHODS This was a retrospective single-center study conducted in a 15-bed trauma ICU of a university-affiliated teaching hospital. Descriptive statistics were used. RESULTS Of 69 patients assessed, 41 had 121 planned procedures over a mean ICU length of stay of 18.7 days (SD 9.6 days). EN was stopped prior to 108 (89 %, 95 % CI 82-94 %) of these 121 procedures, and 102 of these cessation episodes were related to the planned procedure. EN was stopped in 37 patients for a mean cumulative duration of 30.8 h (SD 22.7 h) per patient, which represented 7.9 % (SD 6.9 %) of the mean total time spent in the ICU leading to a mean energy and protein deficit of 7.2 % (SD 8.5 %) and 7.7 % (SD 9.6 %), respectively. Of the 121 planned procedures, 27 (22 %, 95 % CI 16-31 %) were postponed beyond the scheduled day. For 32 (31 %, 95 % CI 23-41 %) of the 102 EN cessation episodes, EN was stopped without a documented order and 23 (23 %, 95 % CI 16-32 %) episodes were not deemed necessary based on the institution's guidelines. CONCLUSION In this ICU cohort, EN cessation for planned procedures was frequent and led to a nutritional deficit due to long periods without EN being delivered. Postponement of procedures and clinically unnecessary EN cessation were important factors that prevented delivery of planned nutrition. EN cessation practice should be a focus for improving EN delivery in ICU patients.
Collapse
|
8
|
Chang YS, Fu HQ, Xiao YM, Liu JC. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R118. [PMID: 23786708 PMCID: PMC4057382 DOI: 10.1186/cc12790] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 06/20/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Enteral feeding can be given either through the nasogastric or the nasojejunal route. Studies have shown that nasojejunal tube placement is cumbersome and that nasogastric feeding is an effective means of providing enteral nutrition. However, the concern that nasogastric feeding increases the chance of aspiration pneumonitis and exacerbates acute pancreatitis by stimulating pancreatic secretion has prevented it being established as a standard of care. We aimed to evaluate the differences in safety and tolerance between nasogastric and nasojejunal feeding by assessing the impact of the two approaches on the incidence of mortality, tracheal aspiration, diarrhea, exacerbation of pain, and meeting the energy balance in patients with severe acute pancreatitis. METHOD We searched the electronic databases of the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE. We included prospective randomized controlled trials comparing nasogastric and nasojejunal feeding in patients with predicted severe acute pancreatitis. Two reviewers assessed the quality of each study and collected data independently. Disagreements were resolved by discussion among the two reviewers and any of the other authors of the paper. We performed a meta-analysis and reported summary estimates of outcomes as Risk Ratio (RR) with 95% confidence intervals (CIs). RESULTS We included three randomized controlled trials involving a total of 157 patients. The demographics of the patients in the nasogastric and nasojejunal feeding groups were comparable. There were no significant differences in the incidence of mortality (RR=0.69, 95% CI: 0.37 to 1.29, P=0.25); tracheal aspiration (RR=0.46, 95% CI: 0.14 to 1.53, P=0.20); diarrhea (RR=1.43, 95% CI: 0.59 to 3.45, P=0.43); exacerbation of pain (RR=0.94, 95% CI: 0.32 to 2.70, P=0.90); and meeting energy balance (RR=1.00, 95% CI: 0.92 to 1.09, P=0.97) between the two groups. Nasogastric feeding was not inferior to nasojejunal feeding. CONCLUSIONS Nasogastric feeding is safe and well tolerated compared with nasojejunal feeding. Study limitations included a small total sample size among others. More high-quality large-scale randomized controlled trials are needed to validate the use of nasogastric feeding instead of nasojejunal feeding.
Collapse
|
9
|
Thomson A, Subramaniam K, Davies A. Nutritional therapy in acute pancreatitis--time to take stock. Nutrition 2012; 28:731-2. [PMID: 22516372 DOI: 10.1016/j.nut.2011.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 12/22/2011] [Indexed: 10/28/2022]
|
10
|
Total parenteral nutrition combined with enteral nutrition in treatment of severe acute pancreatitis. ACTA ACUST UNITED AC 2011. [DOI: 10.3724/sp.j.1008.2011.00737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Germansky KA, Leffler DA. Development of quality measures for monitoring and improving care in gastroenterology. Best Pract Res Clin Gastroenterol 2011; 25:387-95. [PMID: 21764006 DOI: 10.1016/j.bpg.2011.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 05/16/2011] [Indexed: 01/31/2023]
Abstract
Over the past decade, most quality assurance (QA) efforts in gastroenterology have been aimed at endoscopy. Endoscopic quality improvement was the rational area to begin QA work in gastroenterology due to the relatively acute nature of complications and the high volume of procedures performed. While endoscopy is currently the focus of most quality assurance (QA) measures in gastroenterology, more recent efforts have begun to address clinical gastroenterology practices both in the outpatient and inpatient settings. Clinical outpatient and inpatient gastroenterology is laden with areas where standardization could benefit patient care. While data and experience in clinical gastroenterology QA is relatively limited, it is clear that inconsistent use of guidelines and practice variations in gastroenterology can lead to lower quality care. In this review, we review a variety of areas in clinical gastroenterology where existing guidelines and published data suggest both the need and practicality of active QA measures.
Collapse
Affiliation(s)
- Katharine A Germansky
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | | |
Collapse
|
12
|
|